Should we sign our patient’s knee at discharge from rehabilitation like surgeons do before surgery?
Not because we want to autograph our great work, but to signify that we have completed the safety checks to ensure we have removed all modifiable risk factors for injury. Why did surgeons implement signing the operative knee before surgery? As ridiculous as it sounds, the wrong knee had mistakenly been operated on. It doesn’t happen very often, but what it does, it can be catastrophic. Why should rehabilitation providers sign that they have removed all modifiable risk factors after rehabilitation?
Because we are unknowingly discharging numerous patients with modifiable risk factors for future injury. In fact, almost certainly many more patients are being discharged with modifiable risk factors than wrong knees are being operated on — and the long-term consequences can be just as catastrophic.
Let’s hear what happened to Jane:
Jane is a 36-years-old mother of two, whose youngest is 18 months. Since the birth of her children Jane’s priorities have shifted and she no longer gets to the gym as much as she’d like. She enjoys exercises, but with two kids and full-time job it’s hard to squeeze in a regular routine. As a result, Jane has put on few pounds, a fact that pushed her to recommit to getting back into shape despite her busy schedule.
In the course of her new workout routine, she developed hip and knee pain. She went to her physician and he diagnosed her with early onset knee osteoarthritis. How can that be, she’s only 36?
Looking back over Jane’s medical history, we discover that 20 years ago she had an ACL reconstruction, with several months of rehabilitation. Considering this prior injury, was Jane’s early onset of osteoarthritis just a natural course of the ACL tear, or was there something that could have been done differently to prevent her current condition? Let’s look at her post-operatively:
The rehabilitation provider that worked with Jane had her start with basic range of motion and strengthening and then progressed her through a myriad of exercises from low to high level. Finally, Jane was doing plyometrics (programs proven to reduce injury), running, and cutting and was ready to return to sport. Her strength and ROM looked good and so did her running and cutting. Jane said she was feeling great! So she went back to sport.
Here’s the problem: Previous injury is the most consistently reported risk factor for future injury in athletics. Here is one of my favorite injury epidemiologists summarizing his research findings:
“Looking at 70 teams, in 18 countries, over 8 seasons (9,000 injuries), we have found that previous injury is by far the greatest predictor of future injury in football.”
Soccer Industry Medical Symposium 2009
But what is more important is that, numerous researchers have found that modifiable risk factors remain after rehabilitation (eg. jump landing asymmetry remains 2 years after ACL reconstruction and predicts second ACL tear). If you would like to dive into that concept in more depth, check out this short video
What this means is that without standardized, systematic, and stringent return to sport and discharge testing, we are likely to discharge patients with modifiable risk factors. We MUST stop this. Since I have implemented systematic discharge and return to sport testing, I am SHOCKED to find out how frequently I am wrong — the patient appears to be normal (even by my “trained” eye) but testing reveals something completely different.
So, are you willing to sign your patient’s leg, arm or back? I am…..but in the mean time, I have to go apologize to some of my previous patients. Fortunately, Jane is fictional but represents a large percentage of our patients.
Over the next several posts, I hope we can all discuss what the evidenced based discharge tests should be and what is considered passing. What tests do you think should be included? Post them below so we can discuss them in this forum.